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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: _ (Crty fo Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Ovmer Name� <br />Installation Address � ZG ' %� � �"{ <br />i /� <br />Cil/: ��: �`�'t�J � State: l��_ Zi� <br />Mailing Address (ildiBerenQ: <br />City: <br />Email: <br />State: <br />Total Cost to Install Device (/rom con(ractor invoicc)� $ <br />Ptione: ( ) <br />I, lhe property owner, request to have the City of [veretl Backwater Prevenlion Device rebate check <br />for Ihe instal!ation o11he device at lhe abuve referenced property address be made payablc to, and <br />sent to, the vendor specified on ihe back of this form. [3y requesting the rebate cheek be made <br />payab!c lo the vendor, I agree to the following: <br />1. I will nol receive a rebate check direclly from the City of Everett. <br />2. Assigning payment of Ihe reha�e �o the venclor does nol exempt me from f3ackwaler <br />Prevr,ntion Dr,vic�r Rchate Proyiam reyuirements. <br />i au�horite Ihe release of my rebate to lhe vendor listed on Ihe back of this form pending <br />approval of lhe wrr�pleled Backwater Prevenlion Device rebale packel hy the City ol Everett <br />_ fjf ��, _ S � ,�/L,�e�� >, - <br />Sig alure oi roperty Owner <br />�-.�s- - r � <br />Dale <br />